Increased risk for the development of preeclampsia in obese pregnancies: weighing in on the mechanisms

Early age at menarche is associated with an increased risk of preeclampsia and adverse neonatal outcomes: a 6‑year retrospective study

PURPOSE

Preeclampsia affects between 2 to 8% of pregnancies worldwide and is associated with significant adverse outcomes for both mothers and their offspring. The present study aims to investigate whether there is a correlation between early age at menarche and an increased risk of developing preeclampsia and experiencing adverse neonatal outcomes.

METHODS

The study involved a review of medical records of 4227 pregnant women who gave birth at The First Affiliated Hospital of Chengdu Medical College between January 2017 and December 2022. The collected data included demographic characteristics, clinical manifestations of preeclampsia, laboratory indicators, gestational complications, and neonatal outcomes. Pregnant women were categorized into four groups based on their age at menarche (≤ 12, 13, 14, and ≥ 15 years). Logistic regression analysis was conducted to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) for the association between different menarche age groups and the risk of preeclampsia and adverse neonatal outcomes.

RESULTS

Pregnant women who had an age at menarche of ≤ 12 years had a higher risk of preeclampsia than women who had their menarche at 13, 14, and ≥ 15 years of age, with adjusted ORs (95% CIs) for preeclampsia of 1.00 (reference), 0.78 (0.45-0.91), 0.76 (0.59-0.88), and 0.73 (0.56-0.94), respectively. The predictive efficacy of age at menarche for preeclampsia was assessed with a sensitivity and specificity of 85.2% and 76.4%, respectively, and an AUC of 0.82. Moreover, infants born to women with an age at menarche of ≤ 12 years had a higher risk of adverse neonatal outcomes, including small for gestational age, preterm birth, low birth weight, neonatal respiratory distress syndrome, and neonatal intensive care unit admission.

CONCLUSION

Our findings suggest that an early age at menarche is associated with an increased risk of preeclampsia and adverse neonatal outcomes. This information could be useful for obstetricians to identify women at risk for preeclampsia early on and implement timely interventions to reduce the incidence of preeclampsia and associated adverse neonatal outcomes.

Leptin in reproduction and hypertension in pregnancy

Leptin has important roles in numerous physiological functions, including those in the regulation of energy balance, and in immune and reproductive systems. However, in the recent years, evidence has implicated it in a number of obesity-related diseases, where its concentrations in serum are significantly elevated. Elevated serum leptin concentrations and increased placental leptin secretion have been reported in women with hypertensive disorders of pregnancy. Whether leptin is responsible for this disorder remains to be established. Leptin injections in healthy rats and mice during pregnancy result in endothelial activation, increased blood pressure and proteinuria. A potential role for leptin in the pathogenesis of pre-eclampsia is hypothesised, particularly in women who are overweight or obese where serum leptin concentrations are often elevated. This review summarises pertinent information in the literature on the role of leptin in puberty, pregnancy, and hypertensive disorders of pregnancy. In particular, the possible mechanism that may be involved in leptin-induced increase in blood pressure and proteinuria during pregnancy and the potential role of marinobufagenin in this disease entity. We hypothesise a significant role for oxidative stress in this, and propose a conceptual framework on the events that lead to endothelial activation, raised blood pressure and proteinuria following leptin administration.

The Role of Obesity in the Development of Preeclampsia

PURPOSE OF REVIEW

This comprehensive review provides an in-depth exploration of the complex relationship between obesity and preeclampsia (PE) and emphasizes the clinical implications of this association. It highlights the crucial role of screening tools in assessing individual risk and determining the need for additional antenatal care among women with obesity. The review investigates various markers for identifying the risk of developing PE, while emphasizing the significance of interventions such as exercise, weight management, and a balanced diet in reducing the incidence of preeclampsia and improving outcomes for both mother and fetus.

RECENT FINDINGS

Actually, there is a global pandemic of obesity, particularly among women of childbearing age and pregnant women. PE, which is characterized by maternal hypertension, proteinuria, and complications, affects 2-4% of pregnancies worldwide, posing significant risks to maternal and perinatal health. Women with obesity face an elevated risk of developing PE due to the systemic inflammation resulting from excess adiposity, which can adversely affect placental development. Adipose tissue, rich in proinflammatory cytokines and complement proteins, contributes to the pathogenesis of PE by promoting the expression of antiangiogenic factors in the mother. This review emphasizes the need for appropriate screening, interventions, and a holistic approach to reduce the incidence of preeclampsia and enhance maternal-fetal well-being, thus providing valuable insights into the multifaceted association between obesity and PE.

Impact of Race/Ethnicity and Insurance Status on Obstetric Outcomes: Secondary Analysis of the NuMoM2b Study

OBJECTIVE

 This study aimed to investigate the impact of race/ethnicity and insurance status on obstetric outcomes in nulliparous women.

STUDY DESIGN

 Secondary analysis of the Nulliparous Pregnancy Outcomes Study Monitoring Mothers-To-Be. Obstetric outcomes included the development of a hypertensive event during pregnancy, need for a cesarean section, delivery of a preterm neonate, and postpartum hemorrhage.

RESULTS

 Of 7,887 nulliparous women, 64.7% were non-Hispanic White (White), 13.4% non-Hispanic Black (Black), 17.8% Hispanic, and 4.1% were Asian. Black women had the highest rates of developing new-onset hypertension (32%) and delivering preterm (11%). Cesarean deliveries were the highest in Asian (32%) and Black women (32%). Individuals with government insurance were more likely to deliver preterm (11%) and/or experience hemorrhage after delivery. In multivariable analyses, race/ethnicity was associated with hypertension and cesarean delivery. More important, the adjusted odds ratios for preventable risk factors, such as obesity, diabetes, and severe anemia were greater than the adjusted odds ratios for race/ethnicity in terms of poor maternal outcome.

CONCLUSION

 Although disparities were observed between race/ethnicity and obstetric outcomes, other modifiable risk factors played a larger role in clinical differences.

KEY POINTS

· Race or insurance alone had mixed associations with maternal morbidities.. · Race and insurance had low associations with maternal morbidities.. · Other, modifiable risk factors may be more important.. · Both social and biological factors impact health disparities..

Associations between Maternal Nutritional Status, Hemodynamic Parameters, and Delivery Outcomes in Low-Risk Pregnancies: A Prospective Observational Study

Maternal nutritional status represents a pivotal predictor of pregnancy outcome. This prospective observational study investigates the associations between maternal characteristics and nutritional habits at term, hemodynamic parameters, and pregnancy outcomes. Healthy women with singleton uncomplicated pregnancies were enrolled at 36-41 gestational weeks. At enrollment, a nutritional score (0-10) was calculated in order to quantify maternal adherence to a healthy diet and lifestyle. Maternal hemodynamic parameters were assessed by using the Ultrasonic Cardiac Output Monitor (USCOM), including cardiac output (CO), systemic vascular resistance (SVR) and Smith-Madigan inotropy index (SMII). Pregnancy outcomes were recorded at delivery. Associations between maternal characteristics and nutritional score, hemodynamic parameters, and pregnancy outcomes were investigated by using multi-adjusted generalized linear models. In total, 143 pregnancies were enrolled. Pregestational body mass index (BMI) was positively associated with SVR, and negatively associated with CO and SMII. Additionally, a positive association was detected between the nutritional score and SMII. Finally, CO was positively associated with birth and placental weight, while RVS showed a negative association with birth and placental weight. This study shows that maternal derangements in nutritional status and habits are associated with a compromised hemodynamic profile at term, with additional impacts on intrauterine growth.

Associations of Preconception Body Weight, Body Mass Index, and Hypertension with Preeclampsia

Objective: Maximizing preconception health is an important strategy to prevent preeclampsia in pregnancy. Preeclampsia remains a significant cause of maternal and fetal morbidity and mortality. We examined the associations between preconception maternal body weight, body mass index (BMI), and blood pressure with preeclampsia and its related outcomes. Materials and Methods: We performed a retrospective review of 11,214 live births from 6 months preconception during 2009-2018 in the University of Washington medical system. Outcomes were analyzed using chi-square, analysis of variance, and t-tests. Binary logistic regression was performed to examine associations. Results: Of 11,214 births, 1,539 (13.7%) were complicated by preeclampsia. Individuals with preeclampsia weighed more and had higher blood pressure from 6 months preconception to at least 6 months of pregnancy compared with those without preeclampsia (p < 0.001). Persons with prepregnancy systolic blood pressure (SBP) ≥130 mmHg were 3.2 times more likely to develop preeclampsia than those with SBP <130 mmHg (adjusted odds ratio [aOR] = 3.24, 95% confidence interval [CI] = 2.37-4.43). Women with prepregnancy BMI ≥30 kg/m2 were 2.3 times more likely to develop preeclampsia (aOR = 2.31, 95% CI = 1.72-3.10) than those with BMI <30 kg/m2. Mothers with preeclampsia were more likely to deliver preterm (29% vs. 13.8%, p < 0.001) and have neonates with 5-minute Apgar scores <8 (22.1% vs. 12.1%, p = 0.02) and lower preterm birthweights (1,909 g, 95% CI = 1,813-2,004 g vs. 2,057 g, 95% CI = 1,989-2,123 g). Conclusions: Maternal obesity and elevated blood pressure from 6 months preconception to 6 months of pregnancy were associated with preeclampsia, resulting in maternal and fetal complications.

Stroke-related risk factors during pregnancy in women who underwent metabolic and bariatric surgery compared with women who have not undergone metabolic and bariatric surgery

BACKGROUND

Stroke during pregnancy is rare, occurring in 30 of 100,000 pregnancies and accounting for 7% of maternal deaths in the United States from 2016 to 2018. Metabolic and bariatric surgery (MBS) has been shown to reduce symptoms of chronic conditions that are risk factors for stroke, including hypertension, hypercholesterolemia, and diabetes in women. However, little is known about the impact of MBS on stroke risk during pregnancy.

OBJECTIVES

To examine stroke and stroke risk factors including preeclampsia, eclampsia, gestational hypertension, and embolism/thrombosis in women of reproductive age who have had MBS.

SETTING

We used the National Inpatient Sample, a publicly available data set from the Healthcare Cost and Utilization Project that samples 20% of hospital discharges in the United States.

METHODS

This cross-sectional study included women between the ages of 20 and 44 years who had a maternal admission code. Weighted logistic regression was conducted to assess the odds of stroke and stroke risk factors in women with a history of MBS compared with other women of reproductive age.

RESULTS

Women with a history of MBS have 12% lower adjusted odds of developing preeclampsia/eclampsia and 10% lower adjusted odds of gestational hypertension than women who did not undergo MBS. When stratified by race, the difference was significant in White women (preeclampsia/eclampsia: adjusted odds ratio [aOR] = .89; 95% confidence interval [CI], .81-.98; gestational hypertension: aOR = .91; 95% CI, .83-1.00). Latinas with MBS had significantly lower odds of preeclampsia/eclampsia (aOR = .75; 95% CI, .64-.90).

CONCLUSIONS

MBS helps women lose weight and decrease the incidence of some pregnancy-related risk factors for stroke. However, there is a notable racial health disparity.

The association between body mass index and live birth and maternal and perinatal outcomes after in-vitro fertilization: a national cohort study

Objective

To investigate the association between female body mass index (BMI) and live birth rates and maternal and perinatal outcomes after in-vitro fertilization (IVF).

Methods

We performed a national, population-based cohort study including women undergoing IVF between 2002 and 2020. The cohort included 126,620 fresh cycles and subsequent frozen embryo transfers between 2007 and 2019 (subpopulation 1) and 58,187 singleton deliveries between 2002 and 2020 (subpopulation 2). Exposure was female BMI (kg/m2) categorized according to the World Health Organization as underweight (<18.5), normal weight (18.5-24.9, reference), overweight (25.0-29.9), class I obesity (30.0-34.9), class II obesity (35.0-39.9), and class III obesity (≥40.0). The primary outcome in subpopulation 1 was cumulative live birth per started fresh IVF cycle, including fresh and subsequent frozen embryo transfers. Primary outcomes in subpopulation 2 were hypertensive disorders of pregnancy and preterm birth at less than 37 weeks. Risk ratios (RRs) with 95% confidence intervals (CIs) for the association between BMI class and outcomes were calculated using generalized linear models after adjustment for relevant confounders.

Results

The cumulative live birth rate decreased significantly with increasing BMI from 32.6% in normal-weight women to 29.4% in overweight women, 27.0% in women in obesity class I, 21.8% in women in obesity class II, and 7.6% in women in obesity class III. The risk of hypertensive disorders of pregnancy increased significantly and progressively with increasing BMI, from 4.6% in normal-weight women to 7.8% in overweight women and 12.5%, 17.9%, and 20.3% in women in obesity classes I, II, and III. The risk of preterm birth followed a similar pattern, from 6.3% in normal-weight women to 7.5% in overweight women and 8.9%, 9.9%, and 15.3% in women in obesity classes I, II, and III. The risks of other perinatal complications, such as perinatal death, showed an even more pronounced increase.

Conclusion

Using a large and complete national cohort of women undergoing IVF, we demonstrate a dose-dependent decrease in live birth rate and a substantial increase in maternal and perinatal complications with increasing BMI. Strategies to improve this situation are warranted.

Determinants of pre-eclampsia among pregnant women attending antenatal care and delivery services at Bahir Dar public hospitals, northwest Ethiopia: A case-control study

Background and Aims

Pre-eclampsia (PE) is a pregnancy-related syndrome that occurs after 20 weeks of pregnancy. The current study was designed to evaluate the determinants of PE in pregnant women following antenatal and delivery services.

Methods

An institution-based case-control study was performed in governmental hospitals of Bahir Dar city. The data were collected using an interview-administered questionnaire and analyzed by SPSS version 20 software. Bivariate and multivariable logistic regression models were utilized for the analysis of variables. A p < 0.05 was used to declare the level of significance.

Results

In this study, the mean ages (in years) of cases and controls were 28.20 ± 5.66 and 27.52 ± 4.70, respectively. Factors such as: being primiparous (adjusted odds ratio [AOR]: 3.19 at 95% confidence interval [CI]: 1.71, 5.97), family history of hypertension (HTN) (AOR: 4.14 at 95% CI: 1.71, 10.05), previous history of PE (AOR: 7.97 at 95% CI: 2.42, 26.63), number of antenatal care (ANC) visits (AOR: 5.43 at 95% CI: 2.86, 10.33), not taking iron and folic acid supplement (AOR: 4.46 at 95% CI: 1.59, 12.48), body mass index ≥25 kg/m² (AOR: 3.47 at 95% CI: 1.78, 6.77), not consuming vegetables (AOR: 1.99 at 95% CI: 1.07, 3.69) and not consuming egg, milk and milk products (AOR: 3.00 at 95% CI: 1.47, 6.11) were the determinants of PE.

Conclusion

In this study, different determinants of PE were identified. Hence, special attention should be given for primiparous women, women having previous history of PE and family history of HTN. Moreover, nutritional counseling should be given for pregnant women during ANC visits. Besides, higher officials should design an appropriate strategy to increase the number of mothers to complete their ANC visits and to take iron and folic acid supplements. Furthermore, to verify the determinants of PE, community-based cohort studies are warranted.

Health Complications of Obesity: 224 Obesity-Associated Comorbidities from a Mechanistic Perspective

Obesity is associated with a wide range of comorbidities that transverse multiple specialties in clinical medicine. The development of these comorbidities is driven by various mechanistic changes including chronic inflammation and oxidative stress, increased growth-promoting adipokines, insulin resistance, endothelial dysfunction, direct loading and infiltrative effect of adiposity, heightened activities of the renin-angiotensin-aldosterone system and sympathetic nervous system, impaired immunity, altered sex hormones, altered brain structure, elevated cortisol levels, and increased uric acid production, among others. Some of the comorbidities might develop secondary to one or more other comorbidities. Considering the obesity-associated comorbidities in the context of the mechanistic changes is helpful in understanding these conditions and in guiding treatment and future research.

Circulating levels of tissue inhibitor of metalloproteinase 3, a protein with inhibitory effects on angiogenesis, are increased in pre-eclampsia

OBJECTIVE

To assess and compare circulating tissue inhibitor of metalloproteinase 3 (TIMP-3) concentrations between women with pre-eclampsia and healthy pregnant women. We also aimed to determine the relationships between circulating TIMP-3 and matrix metalloproteinase 2 (MMP-2), MMP-9, TIMP-1, and TIMP-2 concentrations in pre-eclampsia.

METHODS

A primary case-control study included patients with pre-eclampsia (n = 219) and gestational hypertension (n = 118), healthy pregnant women (n = 214), and non-pregnant women (n = 66), and a replication case-control study included patients with pre-eclampsia (n = 177) and healthy pregnant women (n = 124), all from southeastern Brazil. Plasma TIMP-3, MMP-2, MMP-9, TIMP-1, and TIMP-2 concentrations were assessed using commercially available enzyme-linked immunosorbent assay kits, and the relationships between them were analyzed using Spearman's correlation.

RESULTS

In our primary study, patients with pre-eclampsia and gestational hypertension exhibited increased TIMP-3 concentrations compared with healthy pregnant women (both P < 0.0001) and non-pregnant women (both P < 0.001). These findings were confirmed in the replication study, showing elevated TIMP-3 concentrations in women with pre-eclampsia versus healthy pregnant women (P < 0.001). We found no difference in TIMP-3 concentrations between early-onset and late-onset pre-eclampsia. Moreover, TIMP-3 concentrations were significantly correlated with plasma concentrations of TIMP-1 (r = 0.2333; P = 0.0086) and MMP-2 (r = 0.2159; P = 0.0156) in pre-eclampsia.

CONCLUSIONS

Circulating TIMP-3 concentration is increased in women with pre-eclampsia compared with healthy pregnant women, and it is positively correlated with plasma MMP-2 and TIMP-1 concentrations in pre-eclampsia.

Mouse models of preeclampsia with preexisting comorbidities

Preeclampsia is a pregnancy-specific condition and a leading cause of maternal and fetal morbidity and mortality. It is thought to occur due to abnormal placental development or dysfunction, because the only known cure is delivery of the placenta. Several clinical risk factors are associated with an increased incidence of preeclampsia including chronic hypertension, diabetes, autoimmune conditions, kidney disease, and obesity. How these comorbidities intersect with preeclamptic etiology, however, is not well understood. This may be due to the limited number of animal models as well as the paucity of studies investigating the impact of these comorbidities. This review examines the current mouse models of chronic hypertension, pregestational diabetes, and obesity that subsequently develop preeclampsia-like symptoms and discusses how closely these models recapitulate the human condition. Finally, we propose an avenue to expand the development of mouse models of preeclampsia superimposed on chronic comorbidities to provide a strong foundation needed for preclinical testing.

Preeclampsia and the Kidney: Pathophysiology and Clinical Implications

Preeclampsia and other hypertensive disorders of pregnancy are major contributors to maternal morbidity and mortality worldwide. This group of disorders includes chronic hypertension, gestational hypertension, preeclampsia, preeclampsia superimposed on chronic hypertension, and eclampsia. The body undergoes important physiological changes during pregnancy to allow for normal placental and fetal development. Several mechanisms have been proposed that may lead to preeclampsia, including abnormal placentation and placental hypoxia, impaired angiogenesis, excessive pro-inflammatory response, immune system imbalance, abnormalities of cellular senescence, alterations in regulation and activity of angiotensin II, and oxidative stress, ultimately resulting in upregulation of multiple mediators of endothelial cell dysfunction leading to maternal disease. The clinical implications of preeclampsia are significant as there are important short-term and long-term health consequences for those affected. Preeclampsia leads to increased risk of preterm delivery and increased morbidity and mortality of both the developing fetus and mother. Preeclampsia also commonly leads to acute kidney injury, and women who experience preeclampsia or another hypertensive disorder of pregnancy are at increased lifetime risk of chronic kidney disease and cardiovascular disease. An understanding of normal pregnancy physiology and the pathophysiology of preeclampsia is essential to develop novel treatment approaches and manage patients with preeclampsia and hypertensive disorders of pregnancy. © 2023 American Physiological Society. Compr Physiol 13:4231-4267, 2023.

Effects of Pre-Pregnancy Overweight/Obesity on the Pattern of Association of Hypertension Susceptibility Genes with Preeclampsia

The aim of this study was to explore the effects of pre-pregnancy overweight/obesity on the pattern of association of hypertension susceptibility genes with preeclampsia (PE). Ten single-nucleotide polymorphisms (SNPs) of the 10 genome-wide association studies (GWAS)-significant hypertension/blood pressure (BP) candidate genes were genotyped in 950 pregnant women divided into two cohorts according to their pre-pregnancy body mass index (preBMI): preBMI ≥ 25 (162 with PE and 159 control) and preBMI < 25 (290 with PE and 339 control). The PLINK software package was utilized to study the association (analyzed four genetic models using logistic regression). The functionality of PE-correlated loci was analyzed by performing an in silico database analysis. Two SNP hypertension/BP genes, rs805303 BAG6 (OR: 0.36−0.66) and rs167479 RGL3 (OR: 1.86), in subjects with preBMI ≥ 25 were associated with PE. No association between the studied SNPs and PE in the preBMI < 25 group was determined. Further analysis showed that two PE-associated SNPs are functional (have weighty eQTL, sQTL, regulatory, and missense values) and could be potentially implicated in PE development. In conclusion, this study was the first to discover the modifying influence of overweight/obesity on the pattern of association of GWAS-significant hypertension/BP susceptibility genes with PE: these genes are linked with PE in preBMI ≥ 25 pregnant women and are not PE-involved in the preBMI < 25 group.

Cardiovascular Dysfunction in Intrauterine Growth Restriction

PURPOSE OF REVIEW

We highlight important new findings on cardiovascular dysfunction in intrauterine growth restriction.

RECENT FINDINGS

Intrauterine growth restriction (IUGR) is a multifactorial condition which negatively impacts neonatal growth during pregnancy and is associated with health problems during the lifespan. It affects 5-15% of all pregnancies in the USA and Europe with varying percentages in developing countries. Epidemiological studies have reported that IUGR is associated with the pathogenesis of hypertension, activation of the renin-angiotensin system (RAS), disruption in placental-mTORC and TGFβ signaling cascades, and endothelial dysfunction in IUGR fetuses, children, adolescents, and adults resulting in the development of cardiovascular diseases (CVD). Experimental studies are needed to investigate therapeutic measures to treat increased blood pressure (BP) and long-term CVD problems in people affected by IUGR. We outline the mechanisms mediating fetal programming of hypertension in developing CVD. We have reviewed findings from different experimental models focusing on recent studies that demonstrate CVD in IUGR.

Systematic review and meta-analysis regarding maternal apelin in pregnant women with and without preeclampsia

Aims: To investigate maternal circulating apelin levels in pregnancies with and without preeclampsia.Design and Method: Systematic review and meta-analysis of observational studies reporting circulating apelin in women who develop preeclampsia. We searched databases for appropriate studies published through December 2021, without language restriction. The quality of studies was evaluated using the Newcastle-Ottawa-Scale. Data were pooled as mean difference (MDs) or standardized MDs (SMDs) and 95% confidence interval (95% CI). A random-effects model enabled reporting of differences between groups, minimizing the effects of uncertainty associated with inter-study variability on the effects of different endpoints.Results: We identified a total of 122 studies, and ten of them reported circulating apelin in women with and without preeclampsia. Maternal apelin did not show a difference in preeclamptic compared to normotensive women (SMD: -0.38, 95%CI -0.91 to 0.15), although there was high heterogeneity between the included studies (I² = 95%). Participants with preeclampsia had higher body mass index, lower gestational age at delivery, and birth weight. Preeclamptic pregnant women with higher BMI showed significantly lower apelin levels in the subgroup analysis. There was no significant apelin difference in the preeclampsia severity sub-analysis.Conclusion: There was no significant difference in apelin levels in pregnant women with and without preeclampsia.

Adverse maternofoetal outcomes associated with ionised calcaemia, total calcaemia, albuminaemia, and calcium supplementation in pregnancy: Analysis from a resource-limited setting

Introduction

Disorders of total calcium (tCa) in pregnancy have been associated with adverse maternofoetal outcomes. However, studies evaluating this from the viewpoint of ionised calcaemia are practically inexistent. This study estimates the prevalence of some adverse maternal and foetal outcomes and the potential effect of ionised calcium (iCa), tCa, albumin and calcium supplementation on some maternofoetal outcomes.

Methods

A cross-sectional study was conducted among 1074 pregnant women in late pregnancy from four health facilities in the Nkongsamba Health District. Data were collected by interview, analysis of maternal blood samples and measurement of maternal and foetal parameters. Total calcaemia and albuminaemia were measured by atomic absorption spectrophotometry, while iCa and pH were measured using ion-selective potentiometry. Associations were measured using the odds ratio in simple and multiple logistic regression.

Results

The prevalence of low birth weight, macrosomia, and hypertension in pregnancy was 6.27 [4.97–7.89]%, 4.78 [3.65–7.89]%, 10.24 [8.57–12.20]%, respectively. Following multiple logistic regression, women with iCa levels ≤ 1.31mmol/L had significantly increased odds of hypertension in pregnancy (AOR = 2.47 [1.63–3.74], p-value = 0.000), having babies with low birth weight (AOR = 2.02[1.33–3.61], p-value = 0.002), low birth length (AOR = 2.00 [1.34–2.99], p-value = 0.001), low brachial circumference (AOR = 1.41[1.10–1.81], p-value = 0.007), first minute Apgar score < 7 (AOR = 3.08[1.70–5.59], p-value = 0.000) and fifth minute Apgar score < 7 (AOR = 2.86[1.32–6.16], p-value = 0.007). Ionised calcaemia had no significant association with maternal body mass index immediately after birth and the head circumference of the baby. Total calcaemia was found to have no significant association with any of the selected outcomes, while women with total albuminaemia ≤ 30mg/L had significantly higher odds of having babies with low birth weight (AOR = 3.40[1.96–5.91], p-value = 0.000), and Apgar scores < 7 at the first (AOR = 2.07[1.16–3.70], p-value = 0.013). Calcium supplementation showed no significant association with any of the selected outcomes except for the first (OR = 0.42[0.24–0.72], p-value = 0.002) and fifth minute Apgar score (OR = 0.25[0.12–0.50], p-value = 0.000).

Conclusion

The prevalence of low birth weight, macrosomia, and hypertension in pregnancy was 6.27 [4.97–7.89]%, 4.78 [3.65–7.89]%, 10.24 [8.57–12.20]%, respectively. Maternal iCa levels ≤ 1.31mmol/L significantly increase the odds of having babies with low birth weight, low birth length, low brachial circumference at birth, low Apgar scores at the first and fifth minutes and maternal hypertension in pregnancy. Low maternal albuminaemia is significantly associated with low birth weight, and Apgar score < 7 at the first minute. None f the selected maternofoetal outcomes directly depend on total calcaemia, given that none of the associations was statistically significant. Even though iCa levels remain relatively normal in normal pregnancies, it remains the strongest predictor of foetal outcomes. Calcium supplementation significantly improves the Apgar scores at the first and fifth minute. Routine pregnancy follow-up should include evaluating maternal calcaemic states, particularly the ionised fraction, to detect the low-normal concentrations likely to impact maternal and foetal outcomes. Normal iCa levels for pregnant women need revisiting.

Dietary factors that affect the risk of pre-eclampsia

Pre-eclampsia affects 3%–5% of pregnant women worldwide and is associated with a range of adverse maternal and fetal outcomes, including maternal and/or fetal death. It particularly affects those with chronic hypertension, pregestational diabetes mellitus or a family history of pre-eclampsia. Other than early delivery of the fetus, there is no cure for pre-eclampsia. Since diet or dietary supplements may affect the risk, we have carried out an up-to-date, narrative literature review to assess the relationship between nutrition and pre-eclampsia. Several nutrients and dietary factors previously believed to be implicated in the risk of pre-eclampsia have now been shown to have no effect on risk; these include vitamins C and E, magnesium, salt, ω-3 long-chain polyunsaturated fatty acids (fish oils) and zinc. Body mass index is proportionally correlated with pre-eclampsia risk, therefore women should aim for a healthy pre-pregnancy body weight and avoid excessive gestational and interpregnancy weight gain. The association between the risk and progression of the pathophysiology of pre-eclampsia may explain the apparent benefit of dietary modifications resulting from increased consumption of fruits and vegetables (≥400 g/day), plant-based foods and vegetable oils and a limited intake of foods high in fat, sugar and salt. Consuming a high-fibre diet (25–30 g/day) may attenuate dyslipidaemia and reduce blood pressure and inflammation. Other key nutrients that may mitigate the risk include increased calcium intake, a daily multivitamin/mineral supplement and an adequate vitamin D status. For those with a low selenium intake (such as those living in Europe), fish/seafood intake could be increased to improve selenium intake or selenium could be supplemented in the recommended multivitamin/mineral supplement. Milk-based probiotics have also been found to be beneficial in pregnant women at risk. Our recommendations are summarised in a table of guidance for women at particular risk of developing pre-eclampsia.

Performance of sFlt-1/PIGF Ratio for the Prediction of Perinatal Outcome in Obese Pre-Eclamptic Women

Obese women are at high risk of developing pre-eclampsia (PE). As an altered angiogenic profile is characteristic for PE, measurement of soluble fms-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PIGF) ratio in the maternal serum can be helpful for PE diagnosis, as well as for adverse perinatal outcome (APO) prediction. There is growing evidence that obesity might influence the level of sFlt-1/PIGF and, therefore, the aim of the study was the evaluation of sFlt-1/PIGF as an APO predictor in obese women with PE. Pre-eclamptic women who had an sFlt-1/PIGF measurement at the time of diagnosis were retrospectively included. Women were classified according to their pre-pregnancy body mass index (BMI) as normal weight (BMI < 25 kg/m2), overweight (BMI > 25−29.9 kg/m2) or obese (BMI ≥ 30 kg/m2). APO was defined as the occurrence of one of the following outcomes: Small for gestational age, defined as a birthweight < 3rd centile, neonatal mortality, neonatal seizures, admission to neonatal unit required (NICU) or respiratory support. A total of 141 women were included. Of them, 28 (20%) patients were obese. ROC (receiver operating characteristic) analysis revealed a high predictive value for sFlt-1/PIGF and APO across the whole study cohort (AUC = 0.880, 95% CI: 0.826−0.936; p < 0.001). However, the subgroup of obese women showed a significantly lower level of sFlt-1 and, therefore, the performance of sFlt-1/PIGF as APO predictor was poorer compared to normal or overweight PE women (AUC = 0.754, 95% CI: 0.552−0.956, p = 0.025). In contrast to normal or overweight women, a ratio of sFlt-1/PIGF < 38 could not rule out APO in women with obesity.

The Regulatory Roles of Chemerin-Chemokine-Like Receptor 1 Axis in Placental Development and Vascular Remodeling During Early Pregnancy

Chemerin is an adipokine that regulates metabolism in pregnancy. An elevation of serum chemerin level is associated with pregnancy complications. Consistently, we demonstrated that the chemerin expression was increased in placenta of preeclamptic patients at deliveries. The G protein-coupled receptor chemokine-like receptor 1 (CMKLR1) mediates the actions of chemerin. The functions of the chemerin-CMKLR1 axis in maintaining pregnancy are still unknown. In this study, we demonstrated that CMKLR1 was expressed in the decidual natural killer (dNK) cells and chorionic villi of human. Chemerin suppressed the proliferation of the dNK cells in vitro. Specific antagonist of CMKLR1, α-Neta abolished the suppressive effect of spent medium from chemerin-treated dNK cells culture on extravillous trophoblast invasion. Activation of the chemerin-CMKLR1 axis promoted fusion and differentiation of human cytotrophoblast to syncytiotrophoblast in vitro. We generated Cmklr1 knockout mice and showed that the Cmklr1 deficiency negatively affected pregnancy outcome in terms of number of implantation sites, litter size and fetal weight at birth. Histologically, the Cmklr1 deficiency impaired formation of the syncytiotrophoblast layer II, induced enlargement of the maternal lacunae in the labyrinth, increased the diameter of the spiral arteries and increased trophoblast invasion in the decidua. The Cmklr1 deficient placenta also displayed an increased number of dNK cells and serum IL-15 level. In summary, the chemerin-CMKLR1 axis regulated placental development and spiral artery remodeling in early pregnancy.

Evaluation of the PLAC8 Gene in Mexican Women With and Without Preeclampsia and Obesity

Preeclampsia (PE) is a leading cause of maternal-fetal mortality worldwide, and obesity is an important risk factor. Genes associated with pathophysiological events common to preeclampsia and obesity, such as PLAC8, remain to be studied; therefore, the aim of the present study was to evaluate this gene in the placentas of women affected with preeclampsia and healthy pregnant women. This case-controlled study included 71 healthy and 64 preeclampsia pregnancies. Gene expression was evaluated in primary human cytotrophoblasts (PHCT) from six normal and six preeclampsia pregnancies, and protein expression was verified in placentas from five healthy and six preeclampsia pregnancies. The whole coding and 5′ regions of the PLAC8 gene were sequenced from healthy (n = 10) and preeclamptic (n = 10) pregnancies. The presence of the observed nucleotide variations was analyzed by RT-PCR in the total population. Statistical analyses were performed accordingly. Obesity was associated with severe preeclampsia (SPE) (OR = 3.34; CI 95% 1.3–8.2, p < 0.01). Significantly higher mRNA and protein expression was observed in preeclamptic vs. healthy placentas (p < 0.05). After sequencing, a single nucleotide variation was identified in 10 cases and one control (p < 0.01), which was then evaluated in the total population showing no association with preeclampsia. This preliminary study confirms the association of SPE with obesity and suggests higher expression of PLAC8 mRNA and protein in placentas from preeclampsia. No differences in nucleotide variations between cases and controls of the whole population were observed. Further research is required to evaluate the implications of higher gene/protein expression in preeclampsia and the causes of such variation.

Uncovering serum placental-related non-coding RNAs as possible biomarkers of preeclampsia risk, onset and severity revealed MALAT-1, miR-363 and miR-17

New predictors that could boost early detection of preeclampsia (PE) and prognosticate its severity are urgently needed. We examined serum miR-17, miR-363, MALAT-1 and HOTAIR as potential biomarkers of PE risk, onset and severity. This prospective study included 160 pregnant females; 82 PE cases and 78 healthy pregnancies. Serum samples were collected between 20 to 40 weeks of gestation. Early-onset PE was defined as developing clinical manifestations at ≤ 34 gestational weeks. Severe PE was defined as systolic blood pressure ≥ 160 mmHg and/or diastolic blood pressure ≥ 110 mmHg and proteinuria (≥ 2 g/24 h or ≥ 2+ dipstick). Selection of PE-related non-coding RNAs and functional target gene analysis were conducted using bioinformatics analysis. Expression profiles were assessed by RT-qPCR. Serum miR-363 and MALAT-1 were downregulated, meanwhile miR-17 was upregulated, and HOTAIR was not significantly altered in PE compared with healthy pregnancies. miR-17 was elevated while miR-363 and MALAT-1 were reduced in severe versus mild PE. miR-363 was lower in early-onset versus late-onset PE. MALAT-1, miR-17 and miR-363 showed diagnostic potential and discriminated severe PE, whereas miR-363 distinguished early-onset PE in the receiver-operating-characteristic analysis. miR-363 and MALAT-1 were significantly associated with early and severe PE, respectively in multivariate logistic analysis. In PE, miR-17 and MALAT-1 were significantly correlated with gestational age (r = - 0.328 and r = 0.322, respectively) and albuminuria (r = 0.312, and r = - 0.35, respectively). We constructed the MALAT-1, miR-363, and miR-17-related protein-protein interaction networks linked to PE. Serum miR-17, miR-363 and MALAT-1 could have utility as new biomarkers of PE diagnosis. miR-363 may be associated with early-onset PE and MALAT-1 downregulation correlates with PE severity.

Fetal Growth and Adipose Fat Tissue Trajectories in Twin Pregnancies after Gastric Bypass Surgery

INTRODUCTION

Previous studies demonstrated a continuous decline in fetal growth throughout singleton pregnancy after bariatric surgery. However, intrauterine growth in twin pregnancy is subjected to further underlying processes. This study was to investigate the longitudinal assessment of fetal biometry and abdominal fat thickness of twin pregnancies conceived after gastric bypass (GB) surgery and compare them to body mass index-matched (BMIM) and obese (OB) controls.

MATERIALS AND METHODS

We retrospectively assessed ultrasound data of 30 women with dichorionic-diamniotic twin pregnancy (11 women after GB surgery, 9 OB mothers with pregestational BMI ≥30 kg/m2, and 10 BMIM and age-matched controls). We assessed fetal growth parameters including fetal subcutaneous adipose tissue thickness (FSCTT) as well as newborn biometry after delivery. Patient characteristics were obtained from the medical records.

RESULTS

The rise in FSCTT curves was markedly slower in the twin offspring of women with history of GB as compared to the offspring of OB mothers and offspring of BMIM controls. Hence, FSCTT was significantly decreased in the GB offspring as compared to both control groups at 34 weeks of gestation. Also, growth curves of abdominal circumference were decreased in the offspring of GB patients as compared to OB mothers. Infants of mothers with history of GB showed significantly lower birth weight percentiles compared to newborns of OB mothers (27.2 vs. 48.8 pct, p = 0.025). There was no significant difference in inter-twin birth weight difference between the offspring of GB (median: 9.9%, interquartile ranges [IQR]: 6.5-20.0) versus OB (median: 14.6%, IQR: 8.2-21.6) and BMIM controls (median: 9.0%, IQR: 6.3-12.6, p = 0.714).

CONCLUSIONS

In summary, intrauterine growth delay in twin pregnancies after GB is assumed to be a multifactorial event with altered metabolism as the most important factor. However, special attention must be paid to the particularity of twin pregnancies as they seem to be subject to other additional mechanism.

Highlighting the Mechanistic Relationship Between Perinatal Depression and Preeclampsia: A Scoping Review

BACKGROUND

Although there is scientific literature supporting an association between depression and preeclampsia (PE), little is known about the underlying mechanistic pathways that may explain these observed associations. Thus, this study aimed to outline the relationship between depression and PE, and to highlight the underlying cardiovascular and metabolic risk factors that are common to both.

METHODS

A scoping review of the literature was conducted in Medline, Scopus, and Web of Science.

RESULTS

From 706 articles initially identified, 23 articles met the inclusion criteria and were included in this review. Although some studies reported a positive association between PE and postpartum depressive symptoms, challenges comparing different methodologies, measurement instruments and when measurements were administered, and patient populations do not permit a decisive conclusion. In addition, very few studies addressed potential underlying mechanisms that may be contributing to observed associations; thus, a secondary search was conducted to identify cardiovascular and metabolic risk factors that are common to both depression and PE.

CONCLUSION

The cardiovascular and metabolic risk factors (i.e., increased inflammation and oxidative stress and decreased vascular and endothelial function) common to both depression and PE suggest that these factors may contribute as underlying mechanisms in both conditions. These similarities underscore the importance to better understand these mechanisms so preventative and therapeutic strategies could be developed to improve maternal health.

Preconceptional maternal weight loss and hypertensive disorders in pregnancy: a systematic review and meta-analysis

BACKGROUND

Hypertensive disorders of pregnancy (HDP), including pregnancy-induced hypertension (PIH), Preeclampsia (PE), Hemolysis Elevated Liver enzymes and Low Platelets (HELLP) and chronic hypertension, are leading causes of maternal and perinatal morbidity and mortality. Although the pathophysiology of HDP is complex, preconceptional weight reduction in obese women might reduce these complications. We conducted a systematic review and meta-analysis to investigate the effectiveness of preconceptional weight loss by lifestyle intervention or bariatric surgery in overweight and obese women and the reduction of the risk of HDP.

METHODS AND RESULTS

Databases are searched until September 2019 resulting in 2547 articles: 110 full-text analysis and 29 detailed analysis. Reduced risks were shown for HDP in seven articles (n = 4381) of weight loss after lifestyle intervention or bariatric surgery (OR range 0.10-0.64), for PIH in four articles (n = 46,976) (OR range 0.14-0.79), and for PE in seven articles (n = 169,734) (OR range 0.14-0.84). The stratified analysis of weight loss after lifestyle intervention and bariatric surgery shows comparable results. The meta-analysis of 20 studies of the effectiveness of lifestyle intervention and bariatric surgery revealed reduced risks of HDP (OR 0.45 (95% CI 0.32-0.63)), PIH (OR 0.61 (95%CI 0.44-0.85)) and PE (OR 0.67 (95%CI 0.51-0.88)).

CONCLUSIONS

Preconceptional weight loss after lifestyle intervention or bariatric surgery is effective in reducing risks of HDP, PIH and PE, and emphasizes the need to optimize weight in overweight and obese women with a child wish. More research is recommended to investigate short-term and long-term beneficial and harmful side-effects of these interventions on maternal and offspring health.

The potential value of diagnostic and predictive serum biomarkers for preeclampsia

BACKGROUND

Preeclampsia (PE), one of the classes of hypertensive pregnancy disorders, is one of the three causes of maternal morbidity and mortality worldwide. The angiogenic and anti-angiogenic factors are useful markers in predicting and diagnosing PE.

AIM

This study aims to detect and measure the serum level of some biomarkers [hypoxia-inducible factor-1 subunit alpha (HIF-1A), vascular endothelial growth factor (VEGF), interferon-gamma-inducible protein of 10 kDa (IP-10), matrix metalloproteinase-13 (MMP-13)] in patients with PE and their correlation with the severity of the disease, to find a good predictor for PE.

PATIENTS, MATERIALS AND METHODS

This prospective study aims to monitor 48 pregnant women who address obstetric consultation and who present risk factors for PE, and a control group with characteristics similar to the study group. Patients were divided into three groups: Group I (n=15) including normal pregnant (NP) women with blood pressure <140∕90 mmHg, without proteinuria, Group II (n=18) including patients with mild PE (MildPE), Group III (n=15) including patients with severe PE (SeverePE). The analysis of serum biomarkers was based on a quantitative sandwich enzyme-linked immunosorbent assay (ELISA), according to the manufacturer's instructions.

RESULTS

In our study, we found that all biomarkers investigated have higher concentrations in the serum of patients with SeverePE and MildPE than those in the control subjects (Group I, NP), the concentrations were increasing along with the disease activity. The means concentrations of HIF-1A, VEGF, IP-10, MMP-13, better correlated with indices in SeverePE group than in MildPE group. We found that VEGF was the biomarker that best correlates with indices that assess the severity of PE. The best separation of patients with SeverePE from those with MildPE can be done with the help of MMP-13 (82% accuracy), followed by VEGF (80.40% accuracy) and the least good detection being done by dosing IP-10.

CONCLUSIONS

We can say that, due to high specificity diagnostic accuracy, determination of serum concentrations of MMP-13 and VEGF, could be useful in the diagnosis and distinguishing of patients with SeverePE and may prove useful in the monitoring of the disease course.

The Effect of Calcium Supplementation on Body Weight Before and During Pregnancy in Women Enrolled in the WHO Calcium and Preeclampsia Trial

INTRODUCTION

Obesity is a major and challenging public health problem. The aim of this substudy is to evaluate the effect of calcium supplementation on body weight in women recruited in the Calcium and Preeclampsia trial.

METHODS

Women were recruited before pregnancy and randomized to receive a calcium supplement containing 500 mg of elemental calcium or placebo until 20 weeks' gestation; all women received 1.5 g from 20 weeks until delivery.

RESULTS

A total of 630 women conceived during the study, 322 allocated to calcium and 308 to placebo. Among these, 230 allocated to calcium and 227 allocated to placebo had information on body weight at baseline and at 8 weeks' gestation. During the study period, women allocated to calcium had a mean weight increase of 1.1 (SD ±5.5) kg, whereas those allocated to placebo had a mean increase of 1.5 (SD ±6.1) kg, a mean difference of 0.4 kg (95% -0.4 (-1.4 to 0.6); P = .408). Women classified as obese at the start of the trial had a lower body weight gain at 8 weeks' gestation (1.0 kg; 95% CI: -3.2 to 1.2; P = .330) and at 32 weeks' gestation (2.1 kg; 95% CI: 5.6-1.3; P = .225) if they received calcium as compared to placebo. However, none of these differences were statistically significant.

CONCLUSION

The smaller increase in body weight found in women supplemented with 500 mg elemental calcium daily is quantitatively consistent with previous studies. However, in this study, the difference was not statistically significant.

Risk Factors for Carbetocin Failure after a Cesarean Section: Is Obesity One of Them?

Obese pregnant women have increased rates of fetal macrosomia, long labor, and cesarean sections, which lead to an increased risk of postpartum hemorrhage (PPH). Carbetocin is useful for the prevention of PPH after a cesarean section. Our study aimed to investigate predictors of carbetocin failure after a cesarean section, and specifically whether obesity is associated with carbetocin failure. We retrospectively analyzed all women who received carbetocin after a cesarean section. Carbetocin failure was defined as changes in hematocrit and hemoglobin, blood loss ≥ 1000 mL, and the need for an additional uterotonic agent or second-line therapies for persistent PPH. Univariate and multivariate analyses were performed to investigate predictors of carbetocin failure. The study included 600 women, with 131 (21.8%) obese women. Overall, 44 (7.3%) carbetocin failures were reported, and rates of obese women were similar between groups (carbetocin failure, 11.4% vs. 22.9%; p = 0.08). Previous PPH (p < 0.001), a cesarean section during labor (p = 0.01), cervical ripening (p = 0.02), and birthweight (p = 0.01) were significantly different between groups. In the multivariable logistic regression analysis adjusted for potential confounders, cervical ripening (adjusted odds ratio (OR) 2.23, 95% confidence interval (CI) 1.01–4.80), compared with spontaneous labor, was significantly associated with carbetocin failure. Obesity was not associated with carbetocin failure after cesarean sections.

Genotypic analysis of the female BPH/5 mouse, a model of superimposed preeclampsia

Animal models that recapitulate human diseases and disorders are widely used to investigate etiology, diagnosis, and treatment of those conditions in people. Disorders during pregnancy are particularly difficult to explore as interventions in pregnant women are not easily performed. Therefore, models that allow for pre-conception investigations are advantageous for elucidating the mechanisms involved in adverse pregnancy outcomes that are responsible for both maternal and fetal morbidity, such as preeclampsia. The Blood Pressure High (BPH)/5 mouse model has been used extensively to study the pathogenesis of preeclampsia. The female BPH/5 mouse is obese with increased adiposity and borderline hypertension, both of which are exacerbated with pregnancy making it a model of superimposed preeclampsia. Thus, the BPH/5 model shares traits with a large majority of women with pre-existing conditions that predisposes them to preeclampsia. We sought to explore the genome of the BPH/5 female mouse and determine the genetic underpinnings that may contribute to preeclampsia-associated phenotypes in this model. Using a whole genome sequencing approach, we are the first to characterize the genetic mutations in BPH/5 female mice that make it unique from the closely related BPH/2 model and the normotensive background strain, C57Bl/6. We found the BPH/5 female mouse to be uniquely different from BPH/2 and C57Bl/6 mice with a genetically complex landscape. The majority of non-synonymous consequences within the coding region of BPH/5 females were missense mutations found most abundant on chromosome X when comparing BPH/5 and BPH/2, and on chromosome 8 when comparing BPH/5 to C57Bl/6. Genetic mutations in BPH/5 females largely belong to immune system-related processes, with overlap between BPH/5 and BPH/2 models. Further studies examining each gene mutation during pregnancy are warranted to determine key contributors to the BPH/5 preeclamptic-like phenotype and to identify genetic similarities to women that develop preeclampsia.

Maternal obesity and developmental programming of neuropsychiatric disorders: An inflammatory hypothesis

Maternal obesity is associated with the development of a variety of neuropsychiatric disorders; however, the mechanisms behind this association are not fully understood. Comparison between maternal immune activation and maternal obesity reveals similarities in associated impairments and maternal cytokine profile. Here, we present a summary of recent evidence describing how inflammatory processes contribute towards the development of neuropsychiatric disorders in the offspring of obese mothers. This includes discussion on how maternal cytokine levels, fatty acids and placental inflammation may interact with foetal neurodevelopment through changes to microglial behaviour and epigenetic modification. We also propose an exosome-mediated mechanism for the disruption of brain development under maternal obesity and discuss potential intervention strategies.

New views on endothelial dysfunction in gestational hypertension and potential therapy targets

The placenta has vital roles in metabolite exchange, fetal growth, and pre-eclampsia (PE). In this review, we discuss the pathogenesis of hypertension in pregnancy, focusing on four major theories to explain PE, discussing endothelial roles in those theories. We focus in particular on the roles of nitric oxide (NO) and prostacyclin (PGI₂) in placental endothelium, and propose new hypotheses for the influence and mechanisms of endothelial NO and PGI₂ signaling pathways in PE.

Pregnancy after bariatric surgery - a narrative literature review

The purpose of this review was to analyze the literature about pregnancy after bariatric surgery. We searched for available articles on the subject from the last decade (2010 to 2020). The positive impact of bariatric surgery on the level of comorbidities and pregnancy and neonatal outcomes cannot be overrated. Weight loss after bariatric surgery reduces the incidence of obesity-related conditions in pregnancy. A pregnancy in a woman after bariatric surgery should be considered a high-risk pregnancy and taken care of by a multidisciplinary team with appropriate micronutrient and vitamin supplementation provided. Optimum time to conception should be chosen following the international recommendations. Every woman after bariatric surgery should be aware of symptoms of surgical complications and immediately contact their surgeon in case of abdominal pain.

Shedding light on the pathophysiology of preeclampsia-syndrome in the era of Cardio-Obstetrics: Role of inflammation and endothelial dysfunction

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Preeclampsia (PE) is a worldwide pregnancy complication with serious maternal and neonatal consequences. Our understanding of PE pathophysiology has significantly evolved over the last decades by recognizing that endothelial dysfunction and systemic inflammation, with an associated angiogenic imbalance, are key pieces of this still incomplete puzzle. In the present era, where no single treatment to cure or treat this obstetric condition has been developed so far, PE prevention and early prediction poses the most useful clinical approach to reduce the PE burden. Although most PE episodes occur in healthy nulliparous women, the identification of specific clinical conditions that increase dramatically the risk of PE provides a critical opportunity to improve outcomes by acting on potential reversible factors, and also contribute to better understand this pathophysiologic enigma. In this review, we highlight major clinical contributors of PE and shed light about their potential link with endothelial dysfunction and inflammation.

Preeclampsia Among African American Pregnant Women: An Update on Prevalence, Complications, Etiology, and Biomarkers

Importance

Preeclampsia is a devastating disease of pregnancy associated with increased risk of fetal and maternal complications. African American pregnant women have a high prevalence of preeclampsia, but there is a need of systemic analyses of this high-risk group regarding complications, etiology, and biomarkers.

Objective

The aim of this study was to provide a synopsis of current research of preeclampsia specifically related to African American women.

Evidence Acquisition

A comprehensive search was performed in the bibliographic database PubMed with keywords "preeclampsia" and "African American."

Results

African American women with preeclampsia were at an increased risk of preterm birth, which resulted in low-birth-weight infants. Intrauterine fetal death among African American preeclamptic patients occurs at twice the rate as in other races. On the maternal side, African American mothers with preeclampsia have more severe hypertension, antepartum hemorrhage, and increased mortality. Those who survive preeclampsia have a high risk of postpartum cardiometabolic disease. Preexisting conditions (eg, systemic lupus erythematosus) and genetic mutations (eg, sickle cell disease in the mother, FVL or APOL1 mutations in the fetus) may contribute to the higher prevalence and worse outcomes in African American women. Many blood factors, for example, the ratio of proteins sFlt/PlGF, hormones, and inflammatory factors, have been studied as potential biomarkers for preeclampsia, but their specificity needs further investigation.

Conclusions

Further studies of preeclampsia among African American women addressing underlying risk factors and etiologies, coupled with identification of preeclampsia-specific biomarkers allowing early detection and intervention, will significantly improve the clinical management of this devastating disease.

Preeclampsia: Linking Placental Ischemia with Maternal Endothelial and Vascular Dysfunction

Preeclampsia (PE), a hypertensive disorder, occurs in 3% to 8% of pregnancies in the United States and affects over 200,000 women and newborns per year. The United States has seen a 25% increase in the incidence of PE, largely owing to increases in risk factors, including obesity and cardiovascular disease. Although the etiology of PE is not clear, it is believed that impaired spiral artery remodeling of the placenta reduces perfusion, leading to placental ischemia. Subsequently, the ischemic placenta releases antiangiogenic and pro-inflammatory factors, such as cytokines, reactive oxygen species, and the angiotensin II type 1 receptor autoantibody (AT1-AA), among others, into the maternal circulation. These factors cause widespread endothelial activation, upregulation of the endothelin system, and vasoconstriction. In turn, these changes affect the function of multiple organ systems including the kidneys, brain, liver, and heart. Despite extensive research into the pathophysiology of PE, the only treatment option remains early delivery of the baby and importantly, the placenta. While premature delivery is effective in ameliorating immediate risk to the mother, mounting evidence suggests that PE increases risk of cardiovascular disease later in life for both mother and baby. Notably, these women are at increased risk of hypertension, heart disease, and stroke, while offspring are at risk of obesity, hypertension, and neurological disease, among other complications, later in life. This article aims to discuss the current understanding of the diagnosis and pathophysiology of PE, as well as associated organ damage, maternal and fetal outcomes, and potential therapeutic avenues. © 2021 American Physiological Society. Compr Physiol 11:1315-1349, 2021.

Body mass index in early-pregnancy and selected maternal health outcomes: Findings from two cohorts in Bangladesh

BACKGROUND

Maternal nutrition is one of the most influential factors that affect the health of the mother and her offspring and remains a significant public health challenge globally. There is a lack of studies evaluating the trends of maternal nutrition and its impact on the burden of pregnancy complications from low-income countries, including Bangladesh. We aimed to determine the burden of early-pregnancy nutrition status based on body mass index (BMI), and the associations of nutritional status with pregnancy-induced hypertension (PIH), cesarean section (CS) delivery, perineal tear and postpartum hemorrhage (PPH) in a rural area in Bangladesh.

METHODS

This prospective study analyzed data from two cohorts: the Maternal, Neonatal, and Child Health (MNCH) project carried out from January 2008 to June 2010, and the Preterm and Stillbirth Study, Matlab (PreSSMat) conducted from October 2015 to March 2018. In total, information of 9287 women who gave birth from the two cohorts was available for analysis. Early-pregnancy BMI was categorized into underweight, normal-weight, and overweight groups. The change in the burden of malnutrition between two cohort periods and the associations between women's BMI and maternal health outcomes were presented in odds ratios (ORs) with their 95% confidence interval (CI).

RESULTS

Between the two cohort periods, the prevalence of underweight decreased from 17.5% to 15.4%, and overweight increased from 10.8% to 20.9%. The risk of being overweight in pregnant women was about two times (OR = 2.19; 95% CI = 1.94-2.46) higher in the PreSSMat cohort than in the MNCH cohort. After multivariate-adjustment for socio-demographic factors, the pooled ORs of PIH, CS delivery, perineal tear, and PPH were 2.41 (95% CI = 1.95-2.99), 2.12 (95% CI = 1.86-2.41), 2.46 (95% CI = 1.54-3.92), and 1.68 (95% CI = 1.12-2.53), respectively, in women with overweight compared to the normal-weight group.

CONCLUSIONS

The results confirmed the existence of a double burden of malnutrition in rural women in Bangladesh. Women with overweight had an increased risk of selected pregnancy complications. The findings call for the adoption of appropriate prenatal counseling and preparedness tailored to women's nutritional status to prevent possible adverse health outcomes.

Weight Gain Before the Third Trimester and Risk of Hypertensive Disorders of Pregnancy: A Prospective Cohort Study

BACKGROUND The association between excessive gestational weight gain (GWG) and the risk of hypertensive disorders of pregnancy (HDP) remains uncertain in women with increased water retention in late gestation associated with the pathophysiology of HDP. This study aimed to investigate the association between GWG before the third trimester and the risk of HDP. MATERIAL AND METHODS This was a prospective cohort study in singleton-pregnant women in Tianjin, China, from 2016. Generalized linear models were used to analyze the relationship between weight gain and the risk of HDP. RESULTS A total of 5295 singleton-pregnant women were included. Even after adjusting for relevant confounders, weight gain at approximately 28 weeks remained an independent risk factor for HDP in the normal-weight group. Compared to the reference of low weight gain (+1 SD was associated with an approximately 2.0 times greater likelihood of HDP (RR: 2.08, 95% CI: 1.06-4.08). Moreover, there was a positive relationship between weight gain in the short interval of early pregnancy and risk of HDP in overweight women. CONCLUSIONS Excessive weight gain before the third trimester was associated with a greater risk of developing HDP among women with early-pregnancy normal weight, which may provide a chance to identify subsequent hypertensive disorders. Additional research is needed to determine whether early-pregnancy weight gain is associated with HDP risk.

Communication practices of healthcare professionals when caring for overweight/obese pregnant women: A scoping review

OBJECTIVE

To synthesize existing research on communication practices between healthcare professionals and overweight and obese pregnant women.

METHODS

Following PRISMA guidance on conducting scoping reviews, we included original research addressing communication/counseling practices of healthcare professionals with overweight and/or obese pregnant women, published between 2008-2018, and available in English. Fourteen articles are included in this review.

RESULTS

Study findings were organized into three themes: (a) topics addressed during encounters, (b) providers' comfort/confidence, knowledge and methods in communicating with overweight/obese pregnant women, and (c) overweight/obese pregnant women's experiences in communicating with healthcare providers. The most prevalent topics addressed were gestational weight gain, physical activity, and nutrition. Healthcare professionals experience discomfort and are reluctant to address weight status with overweight/obese pregnant patients, use vague statements about weight gain and weight-related obstetric risks, and report low confidence when counseling obese pregnant women. Overweight/obese pregnant women perceive weight stigma when interacting with providers.

CONCLUSION

Weight-related counseling in obstetric care is suboptimal. Providers may benefit from training to more confidently and effectively counsel overweight and obese pregnant women about gestational weight gain, physical activity, and nutrition.

PRACTICE IMPLICATIONS

Patients perceive weight stigma in the obstetric setting, which may be prevented by effective, patient-centered communication.

Risk factors and fetal outcomes for preeclampsia in a Colombian cohort

In Latin America and the Caribbean, hypertensive pregnancy disorders are responsible for almost 26% of all maternal deaths [1] and, in Colombia, they account for 59% of all severe maternal morbidity (SMM) cases, and 59.7% of all SMM cases in adolescents [2]. One of the most important hypertensive pregnancy disorders is preeclampsia (PE). Lives can be saved, if PE is prevented, or detected early and properly managed. Prevention and detection depend on identifying the risk factors associated with PE, and, as these have been shown vary by population, they should be determined on a population-by-population basis. The following study utilized the nested case-control model to evaluate 45 potential PE risk factors of a cohort in Bogotá, Colombia, making it perhaps the most comprehensive study of its kind in Colombia. It found PE to have a statistically significant association with 7 of the 45 factors evaluated: 1) pre-gestational BMI >30 kg/m², 2) pregnancy weight gain >12 kg, 3) previous history preeclampsia/eclampsia, 4) previous history of IUGR-SGA (Intrauterine Growth Restriction-Small for Gestational Age), 5) maternal age <20 or ≥35 years (20–34 was not associated), and 6) family history of diabetes. Finally, prenatal consumption of folic acid was found to lower the risk of PE. We recommend that, in Colombia, factors 1–6 be used to identify at risk mothers during pregnancy check-ups; that mothers be encouraged to take folic acid during pregnancy; and, that Colombia's health system and public policy address the problem of pregestational obesity.

Maternal Obesity Does Not Exacerbate the Effects of LPS Injection on Pregnancy Outcomes in Mice

Obesity increases the risk of a number of pregnancy complications, potentially due to chronic inflammation. We predicted that an obesogenic high-fat diet (HFD) in mice would create an inflammatory environment that would exacerbate the effects of lipopolysaccharide (LPS), an inflammatory insult, administered during pregnancy. Females were placed on a HFD or a low-fat diet (LFD) prior to mating, injected with 2 µg LPS or control on gestational day 7 and collected on day 14. Treatment with LPS increased the odds that a female thought to be pregnant at injection had no conceptuses at day 14 (p = 0.024), suggesting that injection with LPS was more likely to induce complete abortion. However, there was no effect of diet on the odds of having no conceptuses at day 14 and no interaction between diet and LPS injection. Diet and LPS injection had no effect on the number of viable fetuses in females still pregnant at day 14. For fetal weight, there was a significant interaction between diet and treatment (p = 0.017), whereby LPS reduced fetal weight in HFD females but not in LFD females. However, LPS treatment of HFD females reduced fetal weight to that observed in control-injected LFD females. Although LPS increased the odds of abortion, there was little evidence that a HFD exacerbated the effects of LPS.

Vascular mechanisms and molecular targets in hypertensive pregnancy and preeclampsia

Preeclampsia is a major complication of pregnancy manifested as hypertension and often intrauterine growth restriction, but the underlying pathophysiological mechanisms are unclear. Predisposing genetic and environmental factors cause placental maladaptations leading to defective placentation, apoptosis of invasive cytotrophoblasts, inadequate expansive remodeling of the spiral arteries, reduced uteroplacental perfusion pressure, and placental ischemia. Placental ischemia promotes the release of bioactive factors into the maternal circulation, causing an imbalance between antiangiogenic soluble fms-like tyrosine kinase-1 and soluble endoglin and proangiogenic vascular endothelial growth factor, placental growth factor, and transforming growth factor-β. Placental ischemia also stimulates the release of proinflammatory cytokines, hypoxia-inducible factor, reactive oxygen species, and angiotensin type 1 receptor agonistic autoantibodies. These circulating factors target the vascular endothelium, causing generalized endotheliosis in systemic, renal, cerebral, and hepatic vessels, leading to decreases in endothelium-derived vasodilators such as nitric oxide, prostacyclin, and hyperpolarization factor and increases in vasoconstrictors such as endothelin-1 and thromboxane A₂. The bioactive factors also target vascular smooth muscle and enhance the mechanisms of vascular contraction, including cytosolic Ca²⁺, protein kinase C, and Rho-kinase. The bioactive factors could also target matrix metalloproteinases and the extracellular matrix, causing inadequate vascular remodeling, increased arterial stiffening, and further increases in vascular resistance and hypertension. As therapeutic options are limited, understanding the underlying vascular mechanisms and molecular targets should help design new tools for the detection and management of hypertension in pregnancy and preeclampsia.

Protein-9 (CTRP9) levels associated with C1q tumor necrosis factor in obese preeclamptic, non-obese preeclamptic, obese and normal pregnant women

AIM

The incidence of obesity and preeclampsia is increasing more and more all over the world. Inflammation and endovascular dysfunction play an important role in the etiopathogenesis of preeclampsia. Obesity has been reported to contribute to the development of preeclampsia by developing a low-grade inflammatory environment and adversely affecting maternal endothelial function. Studies on the relationship between obesity and preeclampsia and how this relationship contributes to endothelial dysfunction continue. The complement C1q tumor necrosis factor-associated protein (CTRP) family (CTRP1-15) secreted from the adipose tissue is a new generation adipokine family with important functions in the immunomodulatory, anti-inflammatory, apoptosis, autoimmunity, vascular system, glucose and lipid metabolism in the body. In recent years, CTRP9, a member of this family, has been shown to have a strong vasorelaxation effect with the Adiponectin Receptor-1/AMPK/eNOS/Nitric Oxide Signaling Pathway. The study aims to find out the role of CTRP9, an adipocytokine, in the pathogenesis of obesity and preeclampsia.

MATERIAL AND METHOD

The CTRP9 levels were measured by the enzyme-linked immunosorbent assay (ELISA) in 40 obese preeclamptic, 40 non-obese preeclamptic, 40 obese pregnant women and 40 normal BMI (Body mass index) pregnant women.

RESULTS

The CTRP9 level of the obese preeclampsia group was found to be lower compared to the non-obese preeclampsia, obese pregnant and normal BMI pregnant control groups (p < .001). The obese preeclampsia group had higher systolic and diastolic blood pressure values compared to the non-obese preeclampsia group (p < .001). There was no difference between the CTRP9 levels of the normal BMI and non-obese preeclampsia groups (p > .05). The serum CTRP9 levels were inversely correlated with age, BMI, blood pressure, and aspartate aminotransferase (AST) (p < .001).

CONCLUSION

Obesity causes a decrease in CTRP9 levels and contributes to the pathogenesis of preeclampsia with adverse effects on the vascular and placental system. Serum CTRP9 levels in pregnant women help identify pregnancies at risk in terms of obesity and preeclampsia.

Cardiac, renal and uterine hemodynamics changes throughout pregnancy in rats with a prolonged high fat diet from an early age

Objective

To examine whether the cardiac, renal and uterine physiological hemodynamic changes during gestation are altered in rats with an early and prolonged exposure to a high fat diet (HFD).

Methods

Arterial pressure and cardiac, renal, uterine and radial arteries hemodynamic changes during gestation were examined in adult SD rats exposed to normal (13%) (n = 8) or high (60%) (n = 8) fat diets from weaning. Plethysmography, high-resolution high-frequency ultrasonography and clearance of an inulin analog were used to evaluate the arterial pressure and hemodynamic changes before and at days 7, 14 and 19 of gestation.

Results

Arterial pressure was higher (P<0.05) in rats with high than in those with normal (NFD) fat diet before pregnancy (123 ±3 and 110 ±3 mmHg, respectively) and only decreased at day 14 of gestation in rats with NFD (98±4 mmHg, P<0.05). A significant increment in stroke volume (42 ±10%) and cardiac output (51 ±12%) was found at day 19 of pregnancy in rats with NFD. The changes in stroke volume and cardiac output were similar in rats with NFD and HFD. When compared to the values obtained before pregnancy, a transitory elevation in renal blood flow was found at day 14 of pregnancy in both groups. However, glomerular filtration rate only increased (P<0.05) in rats with NFD at days 14 (20 ±7%) and 19 (27 ±8%) of gestation. The significant elevations of mean velocity, and velocity time integral throughout gestation in radial (127 ±26% and 111 ±23%, respectively) and uterine (91 ±16% and 111 ±25%, respectively) arteries of rats with NFD were not found in rats with an early and prolonged HFD.

Summary

This study reports novel findings showing that the early and prolonged exposure to a HFD leads to a significant impairment in the renal, uterine and radial arteries hemodynamic changes associated to gestation.

Obesity and cardiovascular disease in women

As the prevalence of obesity continues to grow worldwide, the health and financial burden of obesity-related comorbidities grows too. Cardiovascular disease (CVD) is clearly associated with increased adiposity. Importantly, women are at higher risk of CVD when obese and insulin resistant, in particular at higher risk of developing heart failure with preserved ejection fraction and ischemic heart disease. Increased aldosterone and mineralocorticoid receptor activation, aberrant estrogenic signaling and elevated levels of androgens are among some of the proposed mechanisms explaining the heightened CVD risk. In addition to traditional cardiovascular risk factors, understanding nontraditional risk factors specific to women, like excess weight gain during pregnancy, preeclampsia, gestational diabetes, and menopause are central to designing personalized interventions aimed to curb the epidemic of CVD. In the present review, we examine the available evidence supporting a differential cardiovascular impact of increased adiposity in women compared with men and the proposed pathophysiological mechanisms behind these differences. We also discuss women-specific cardiovascular risk factors associated with obesity and insulin resistance.

Maternal obesity reduces placental autophagy marker expression in uncomplicated pregnancies

AIM

Obesity has been associated with changes in autophagy and its increasing prevalence among pregnant women is implicated in higher rates of placental-mediated complications of pregnancy such as pre-eclampsia and intrauterine growth restriction. Autophagy is involved in normal placentation, thus changes in autophagy may lead to impaired placental function and development. The aim of this study was to investigate the connection between obesity and autophagy in the placenta in otherwise uncomplicated pregnancies.

METHODS

Immunohistochemistry and western blot analysis were done on placental and omental samples from obese (body mass index [BMI] ≥30 kg/m² ) and normal weight (BMI <25 kg/m² ) pregnant women with singleton pregnancies undergoing planned Caesarean delivery without labor at term. Samples were analyzed for autophagic markers LC3B and p62 in the peripheral, middle and central regions of the placenta and in omental adipocytes, milky spots and vasculature.

RESULTS

As pre-pregnancy BMI increased, there was an increase in both placental and fetal weight as well as decreased levels of LC3B in the central region of the placenta (P = 0.0046). Within the obese patient group, LC3B levels were significantly decreased in the placentas of male fetuses compared to females (P < 0.0001). Adipocytes, compared to milky spots and vasculature, had lower levels of p62 (P = 0.0127) and LC3B (P = 0.003) in obese omenta and lower levels of LC3B in control omenta (P = 0.0071).

CONCLUSION

Obesity leads to reduced placental autophagy in uncomplicated pregnancies; thus, changes in autophagy may be involved in the underlying mechanisms of obesity-related placental diseases of pregnancy.

Impact of obesity on the prognosis of hypertensive disorders in pregnancy

The prevalence of pathologies due to placental dysfunction superimposed on pregnancy is constantly increasing. The prognosis of the cases complicated by gestational hypertension is usually good, significantly better compared with that of the cases associating preeclampsia. About half of the cases with gestational hypertension will progress to preeclampsia, the risk of decompensation being inversely proportional to the gestational age of the onset of gestational hypertension. The present study, analyzed the cases of pregnancy and postpartum complicated by pathologies related to placental dysfunction, during a period of 5 years. The risk factors analyzed were the presence of infections during pregnancy, diabetes, thrombophilia, pregnancy obtained by in vitro fertilization, abnormal adherence of the placenta, obesity, multiple pregnancy, the presence of an earlier hepatic, endocrine, renal, cardiac or autoimmune pathology, and the existence of an uterine malformation. Obesity appears with a significantly increased incidence in patients with gestational hypertension and middle preeclampsia. Intrauterine growth restriction appears with a significantly increased incidence in patients with mild preeclampsia. Complications such as prematurity, acute fetal distress and abruption of placentae had a significantly increased incidence in patients with severe preeclampsia. Thus, obese patients have a higher risk of moderate preeclampsia, following gestational hypertension and finally severe preeclampsia.

Oxidative stress in pregnancy complicated by preeclampsia

Preeclampsia is a multisystemic disorder of pregnancy that causes perinatal morbidity and mortality. Studies published in the last decade have contributed to a better understanding of physiopathogenesis through key mechanisms involved, such as altered immune response, endothelial dysfunction, oxidative stress and systemic inflammatory response, as well as genetic susceptibility. Oxidative stress (OS) plays an important role in the development of preeclampsia, since it alters placental remodeling and placental vascular endothelial dysfunction, resulting in an ischemia/reperfusion injury with an increase in xanthine oxidase activity that produces high levels of reactive oxygen species (ROS). ROS can be generated through many pathways within cells, mitochondria, endoplasmic reticulum (ER) and enzymes such as NADPH oxidase are the most important sources, causing widespread and indiscriminate damage to cells and tissues, which leads to an intravascular inflammatory response and maternal systemic endothelial dysfunction characteristic of this prenatal syndrome. Therefore, the following review aims to identify the main risk factors and the role of OS as a pathophysiological mechanism in the development of preeclampsia.

Melanocortin-4 Receptor Deficiency Attenuates Placental Ischemia-Induced Hypertension in Pregnant Rats

Preeclampsia is a pregnancy-specific disorder of new-onset hypertension linked to placental ischemia. While obesity is a major risk factor for preeclampsia, not all obese pregnant women develop pregnancy-induced hypertension or preeclampsia. Previously, we reported that placental ischemia-induced hypertension is dependent upon intact signaling of the sympathetic nervous system. Moreover, in various models of obesity, blockade of MC4R (melanocortin-4 receptor) signaling protects against the development of hypertension via suppression of the sympathetic nervous system. Less is known about this pathway during obese pregnancy. Although blockade of MC4R may lead to increased body weight during pregnancy, we tested the hypothesis that placental ischemia-induced hypertension is attenuated in obese MC4R-deficient pregnant rats. On gestational day 14, MC4R wild-type or heterozygous-deficient (MC4R-def) rats were subjected to chronic placental ischemia via the reduced uterine perfusion pressure procedure or Sham surgery then examined on gestational day 19. In Sham MC4R-def versus Sham wild-type pregnant rats, there was increased body weight, fat mass, and circulating leptin levels but they had similar fetus weights. Reduced uterine perfusion pressure reduced fetus weights in both strains. Reduced uterine perfusion pressure increased blood pressure in wild-type rats but this response was significantly attenuated in MC4R-def rats, although blood pressure was elevated in Sham MC4R-def over Sham wild-type. These data indicate that while obese MC4R-def pregnant rats have higher blood pressure during pregnancy, placental ischemia-induced hypertension is attenuated in obese MC4R-def pregnant rats. Thus, obese women with abnormal MC4R signaling may be less susceptible to the development of placental ischemia-induced hypertension.